Editor’s note: This story references suicide. If you or a loved one is in crisis, resources are available here.
By the time the retired pilot came to Dr. Berit Madsen, he was dealing with unbearable pain.
Suffering from a cancerous mass in his jaw, he waited months to ask his regular oncologist about accessing life-ending medication through the state’s Death with Dignity Act. He knew that physician, from a Catholic-affiliated health system on the Kitsap Peninsula, was bound by rules against providing such medication.
When the pilot finally brought it up, his doctor referred him to Madsen, a radiation oncologist who started the process, allowed to patients with less than six months to live. But despite the nearly 80-year-old being a “tough guy,” as Madsen remembers, he couldn’t wait any longer.
He went into his backyard one morning and fatally shot himself.
To Madsen, the violent death represents the dangers of Washington’s largely consolidated health care system, which has left almost half of the state’s hospital beds — as well as an increasing number of doctors’ offices, hospices and other medical facilities — affiliated with Catholic institutions that restrict certain types of care.
Catholic health care is a huge industry in the U.S., often known for high-quality, mission-driven service — and the ethical and religious directives many of their facilities follow.
Carried out with varying degrees of strictness and workarounds, the directives prohibit medical aid in dying, abortion, some types of fertility treatments and contraception, including tubal ligations and vasectomies. Such facilities also do not typically offer some forms of care for transgender patients.
Mounting concern about those prohibitions has led Madsen and others to call for more oversight of health care mergers, acquisitions and affiliations, similar to policies in Oregon and California.
Senate Bill 5241, dubbed the Keep Our Care Act, would authorize Washington’s attorney general to launch a public process to review such transactions and determine whether any would diminish access to affordable care, including reproductive health, end-of-life, and gender affirming services. If so, the attorney general could impose conditions or reject transactions altogether.
A version of the legislation — also intended to guard against consolidated systems’ rising prices and reduced services due to cost-cutting and perceived efficiencies — died in committee last year. But Attorney General Bob Ferguson and Gov. Jay Inslee support the bill, and leaders from the nonprofit Pro-Choice Washington, who call the legislation a top priority, say they’re hearing growing enthusiasm as lawmakers seek to shore up reproductive health care in the wake of the U.S. Supreme Court’s overturning of Roe v. Wade.
It is, however, a turbulent time for health care systems, facing financial and other pressures from the COVID-19 pandemic. Opponents argue “a sweeping new regulatory scheme,” in the words of one critic, could cause delays and obstacles that torpedo mergers needed to save fragile institutions.
“We may have hospitals that don’t exist,” said Chelene Whiteaker of the Washington State Hospital Association.
Denied care, difficult access
Washington has one of the highest rates of religiously affiliated hospitals in the U.S., with several counties lacking even one secular hospital, according to a 2021 analysis by the state Insurance Commissioner’s office.
Swedish in 2012 formed an alliance with Providence, a multistate Catholic corporation, and Virginia Mason merged with CHI Franciscan in 2021, becoming part of CommonSpirit Health, another national player in Catholic health care.
Providence and Virginia Mason Franciscan Health consider some of their hospitals to be secular: Swedish facilities in the Puget Sound area and Kadlec Regional Medical Center in the Tri-Cities for Providence; and Kitsap County’s St. Michael Medical Center and Seattle’s Virginia Mason Medical Center for the Franciscan system.
But the mergers did not leave those hospitals, and the clinics associated with them, untouched by religion. For instance, internal policies governing St. Michael providers (viewed by The Seattle Times) assert “human life is a gift of God,” that “all health care facilities under our sponsorship should protect life from conception through death” and “Catholic health care institutions may never condone or participate in euthanasia or assisted suicide in any way.”
Religious alliances have also, at times, sparked community backlash.
When the Seattle Sounders announced a partnership with Providence last month, the council representing season ticket holders objected to the health system’s policies around abortion and transgender care, as well as its treatment of low-income patients. (Ferguson is suing Providence for allegedly failing to abide by charity care obligations, charges the nonprofit denies).
Providence does not allow “elective” (as opposed to medically necessary) abortions at its locations, including Swedish locales, and in 2019 settled an ACLU of Washington lawsuit claiming a Swedish clinic discriminated against transgender patients.
Since then, Swedish started an LGBTQIA+ program. Some providers were already treating transgender patients, including by performing gender affirming surgery, and Swedish has now expanded those offerings, according to Dr. Kevin Wang, the program’s medical director.
Providence facilities will perform some gender affirming surgeries, but not on “primary” sex organs such as the uterus, according to spokesperson Melissa Tizon.
Providence’s abortion policy, the main nod to Catholic values in its contract with Swedish, initially alarmed the secular hospital’s OB-GYNs, recalled Dr. Tanya Sorensen, now Swedish’s executive medical director for women and children. But in practice, she said, it’s had little effect.
Because most abortions are done in clinics or private practices rather than hospitals, the policy comes up most frequently in cases of fetal anomalies that do not threaten the pregnant patient’s health or mean the baby would die outside the womb.
Swedish will perform what it considers elective abortions in those cases, Sorensen said. But “trying to be compliant with the [Providence] affiliation,” they will do so at independent clinics and offices where they also practice, often adjacent to Swedish facilities.
Consequently, a nearby Planned Parenthood clinic — funded by Swedish as the merger loomed to appease community objections — was so little used that it closed in 2021. “We just weren’t getting the referrals,” said Chris Charbonneau, then head of the regional Planned Parenthood affiliate.
But things work differently at other religiously run facilities. In 2021, the ACLU of Washington documented patterns by religious hospitals of refusing or delaying terminations of pregnancies with complications, even if a mother’s health was at stake. A 2021 state law, reinforced by guidance from the Biden administration last year, requires health care organizations to allow providers to perform abortions in such situations.
The problem isn’t entirely solved, though, said Dr. Kate McLean, Washington chair of the American College of Obstetricians and Gynecologists. “It still leaves the physician standing a bit alone,” she said. Those making the call to do an abortion can be perceived as challenging a hospital’s ethos and have to get other staff on board.
In a January hearing on the Keep Our Care Act, sponsor and Bremerton Democrat Sen. Emily Randall said she’s heard “story after story” from neighbors and people across the state who have been denied various types of care, or driven long distances to get it.
“Now, there is no secular hospital here on the Kitsap Peninsula,” Randall added in an interview, excepting a Naval facility not open to all.
Victoria Torres-Vandeman lives on the peninsula, as did her late mother, Maria Meyer, who struggled with cancer for years. Terrified of pain, Meyer repeatedly told her oncologist she wanted to use lethal medication when the time came, and her oncologist promised to help.
But the oncologist, after becoming part of the Franciscan system, said that was impossible, according to Torres-Vandeman and an interview Meyer did last spring with a Kitsap Sun columnist, Dr. Niran Al-Agba.
Meyer was angry. She found another doctor able to prescribe life-ending medication, though in the end, she didn’t end up using it. Months after her mom’s death, Torres-Vandeman remains angry too. “That’s not fair, to impose your views on people that are looking for their own health care,” she said.
Torres-Vandeman, her husband and two grown children have all written advance directives to be transferred to a secular facility should they be brought to a religious one in an emergency.
Because the nonreligious options are limited in a small community like hers, Torres-Vandeman said “there’s a real fear in this area.” If those options close, residents are left without choices, she said.
But if some medical establishments shutter because of blocked mergers, opponents of the Keep Our Care Act say, some communities will lose all the services they offered, not just the ones barred for religious reasons.
The legislation’s opponents also say there’s already extensive oversight of consolidations, including attorney general review for possible antitrust violations. The attorney general does not, however, have authority to modify or reject transactions because they would affect care, said Brionna Aho, a spokesperson for the office.
Providence and Virginia Mason Franciscan Health spokespeople said they were still reviewing the bill but defended their systems.
“The affiliation between Providence and Swedish has demonstrated its value many times over the last 10 years, especially during the pandemic,” Tizon, the Providence spokesperson, said in an email. Beginning with Providence Everett admitting the country’s first known COVID patient, clinicians across the system collaborated to coordinate care, she said.
Kelly Campbell, a Virginia Mason Franciscan Health vice president, said in an email that the merger “was done with the intention of expanding care options and access points for patients.” The organization has already expanded the St. Michael campus, home health care and pharmacy services, and it plans to open the state’s first hybrid emergency room and urgent care center.
“I stopped doing it”
Kitsap County oncologist Dr. Dennis Willerford began helping people access the Death with Dignity Act soon after it went into effect in 2009.
“It wasn’t easy,” Willerford said. “It haunts you.” But he said he felt like it was his professional obligation as he took care of dying patients.
His practice was then part of the Harrison Medical Center system, as the region’s century-old hospital used to be known. Like many hospitals, religious or not, Willerford said, Harrison declined to have life-ending medication administered on its grounds.
Executives, nevertheless, “made it pretty clear … what you do behind closed doors, in an exam room where the patient is, is up to you,” Willerford continued. The Death with Dignity process is not just about administering medication. Two doctors need to provide a written diagnosis and, after a 15-day waiting period, one writes a prescription.
One of Willerford’s patients was Dr. Madsen’s father, Arne Madsen, who suffered from a form of cancer that spread into his bones, causing them to snap and him to gradually lose function in his arms and legs.
“So one day, he said to me, ‘Isn’t there just a pill that can end this?’ “ Madsen recalled. “I said, ‘Actually, there is.’ “
She sent him to Willerford, who helped him access the medication.
Madsen saw her father’s death a decade ago as extremely peaceful. In the days before, she said, “he took care of a lot of things to make sure my mom was going to be OK.”
He changed the oil in the car, rotated the tires and got ink for the printer. The family drank the good stuff from the wine cellar, fixed his favorite foods and, on the appointed day, gave him the medication while he sat on the patio.
That experience stands in sharp contrast to the death of Madsen’s patient who shot himself. Driving home the policy question, in Madsen’s eyes, is that the pilot’s regular doctor, the one who couldn’t provide aid in dying, was Willerford.
By that time, Willerford had became part of CHI Franciscan, a merger preceding the alliance with Virginia Mason. While assuring staff and the public that the hospital would remain secular, leaders took a harder line on Death with Dignity, saying in part that doctors wouldn’t be covered by the hospital’s malpractice insurance if they participated, according to Willerford.
“So I stopped doing it,” he said.
Campbell, the Virginia Mason Franciscan Health vice president, said the system’s doctors are free to volunteer independently. And some doctors employed by religiously affiliated corporations have gone that route, volunteering with End of Life Washington, which supports people through the Death with Dignity process, according to Dr. Jessica Kaan, the organization’s medical director. The state began offering free malpractice insurance to volunteer medical providers in 2017.
Still, Kaan said she’s heard from doctors who believe their organization’s policies prevent them from participating even on their time off, for no pay.
It’s uncertain how much the Keep Our Care Act would change that and other aspects of the health care landscape.
“I don’t think there are lots of big health care mergers waiting to happen,” said Douglas Ross, a University of Washington law professor who maintains the bill’s provisions are onerous and unnecessary.
Susan Young, co-founder of a group called Save Secular Health Care Washington, put it another way: “A lot of damage has already been done.” She would like the Keep Our Care Act to have a retroactive component.
Over the years, Young, 71, has been affected by three health care mergers with religiously affiliated institutions, on the San Juan Islands where she once lived, in Kitsap County, where she now resides, and in Seattle.
Most recently, her quest for secular care led her to Virginia Mason, requiring ferry rides back and forth from Bremerton — an all-day affair.
Then came Virginia Mason’s merger, which brought that hospital in line with the Franciscan health system’s policies against elective abortions and medical aid in dying.
Young looked at her dwindled options. She now finds care at the University of Washington.
